The Journal of Mind and Behaviour, Spring 1996, Volume 17, Number 2 Pages 135-160

Mad Liberation: The Sociology of Knowledge and the Ultimate Civil Rights Movement

Robert E. Emerick

San Diego State University

Abstract

Mad liberation -the former mental patient self-help movement -is characterized in this paper as a true progressive social movement. A sociology of knowledge perspective is used to account for much of the research literature that argues, to the contrary, that self-help groups do not represent a true social movement. Based on the "myth of individualism" and the "myth of simplicity," the psychological literature on self-help has defined empowerment in self-help groups as an individual-change or therapeutic orientation. This paper, adopting a sociological perspective, argues that, in fact, empowerment in the mad liberation movement is typically a socio-political concept used to promote social change and the civil rights of mental patients. Accordingly, examples of social changes brought about by members of the mad liberation movement are cited in support of the claim that this movement fits the criteria of a progressive social movement.

Introduction

How is it possible for different researchers to look at the same reality and come away with diametrically opposed interpretations of it? The perspective known as the sociology of knowledge explains that one's interpretation of "reality" is a reflection of one's biases and theories about the nature of knowledge and science. These biases are, in turn, a function of one's background and training, and one's time and place in social history (Berger and Luckmann, 1967; Horowitz, 1961; Mannheim, 1936; Radnitzky and Bartley, 1987; Scheler, 1980; Woolgar, 1988). This paper looks at the background and training of different scholars who have studied the "self-help movement," in particular the mad liberation movement of former mental patient self-help groups, and who have come to very different conclusions regarding its "social movement" status.

"Mad liberation" is my label for that portion of the broader self-help movement that consists of various types of "mental patient," generally former mental patient, self-help groups. Mad liberation also reflects my claim, documented throughout this paper, that mental patient self-help groups are predominantly politically progressive organizations that constitute a true social movement. However, I take my cue from members of the mental patient movement who variously refer to "the mental patients' liberation front," or "the insanity liberation movement" and call themselves "psychiatric inmates," "psychiatric survivors," or "mad activists."

A review of the self-help research literature reveals that the earlier, more conservative interpretations of the mental patient self-help movement are related to the particular academic training and ongoing occupational contexts of most students of this phenomenon, who are usually psychologically (individualistically)-oriented scholars. This paper argues, from a sociological perspective, that new evidence supports the contrary interpretation that the mad liberation movement is a progressive social movement. Many examples of political and legal advocacy and significant social changes brought about by members of the mad liberation movement are presented in support of this claim. First, however, a brief review of the self-help research literature is in order.

Review of the Self-Help Research Literature

The Duality of Empowerment

A central, organizing idea in the study of self-help groups is captured in the concept of "empowerment..' which is generally considered to constitute the major goal of mutual aid and self-help groups, and is often used by researchers to measure the efficacy of self-help group activities. Although there are many formulations of the concept, the classic definition of empowerment is the one developed by Rappaport (1987) during his own extensive study of a self-help organization. Empowerment is defined as "the degree to which individuals, groups, or the environment are changed so that individuals gain more control over the environment" (p. 121, emphasis added). Rappaport thus sees empowerment as including the dual functions of providing a "psychological sense of personal control or influence and a concern with actual social influence, political power, and legal rights" (p. 121).

Most of the research on self-help has concentrated on the individualistic interpretation of empowerment, as individual change and personal control, to the exclusion of the social interpretation, involving changes to the environment through political-legal activism. Emphasis on the individualistic interpretation of empowerment is not surprising in a field dominated by psychological, psychiatric, and social work researchers who, by virtue of their academic training and professional work environment, often perceive "the world of problems" in terms of intra-individual disorders, maladjustments, and diseases.

Is Self-Help a Social Movement?

A review of the self-help research literature over the past twenty years reveals that, indeed, much of this work was done by psychologically-oriented scholars who suggested that most self-help groups serve the therapeutic adjustment needs of deviant or disordered individuals (Borman, Borck, Hess, and Pasquale, 1982; Galanter, 1988; Gartner and Riessman, 1977; Kurtz, 1988; Lieberman and Borman, 1979; Luke, Rappaport, and Seidman, 1991; Pancoast, Parker, and Froland, 1983; Rappaport, Seidman et al., 1985; Richardson and Goodman, 1983; Zimmerman et al., 1991) and that, as such, self-help groups do not qualify as a true social movement (Katz, 1981; Katz and Bender, 1990). By contrast, my training as a sociologist and my research on former mental patient self-help groups lead me to the conclusion that many self-help groups, and particularly those 1 call the mad liberation movement, clearly are a social movement with a progressive social change orientation. Several other scholars and participants in the mad liberation movement agree with this social movement characterization (Borkman, 1990; Chamberlin, 1978, 1990; Everett, 1994; Katz, 1993; McKinnon, 1986; Medvene, 1985; Pilgrim and Rogers, 1993; Rogers and Pilgrim, 1991; Scotch, 1988, 1989). However, it is important to point out that the few academic researchers who take this social movement position are primarily sociologists by academic training and professional involvement.

Self-help is typically viewed by psychological researchers as a kind of "alternative therapy" that bears no relationship to the social movements defined and documented in the more progressive sociological literature. By contrast, my research on ex-mental patient self-help groups provides evidence that there is an emerging national self-help and civil rights social movement (Emerick, 1989, 1990, 1991, 1992, 1995). The failure to detect the mad liberation movement is due, in large part, to the psychologistic theoretical and methodological biases of most of the researchers who, nonetheless, acknowledge the growth of the self-help phenomenon.

The Proliferation of Self-Help Groups and the Self-Help Movement

The increasing popularity and national visibility of self-help groups is demonstrated by cover story articles in such magazines as Psychology Today (Hurley, 1988) and Newsweek (Leerhsen, Lewis, Pomper, Davenport, and Nelson, 1990). More scholarly reviews of the research literature also attest to the proliferation of self-help and mutual aid groups (Levine, 1988; Maton, Leventhal, Madera, and Julien, 1987; Tracy and Gussow, 1976; Zimmerman et al., 1991). In 1981 Katz reviewed the research on self-help throughout the decade of the 1970s, and in 1990 Kurtz reviewed the self-help research during the 1980s. Both historical reviews imply that self-help is a social movement. Katz's review ("Self-Help and Mutual Aid: An Emerging Social Movement?") suggests that by 1981 there were signs that self-help groups were beginning to organize themselves into "an emerging social movement." However, Katz neither conceptualises a definition of what constitutes a social movement, nor does he clarify what kinds of empirical data would be required to justify this conclusion. Similarly, Kurtz's 1990 review of the literature ("The Self-Help Movement: Review of the Past Decade of Research") suggests that self-help is a social movement, but again this paper does not include a definition or a discussion of the concept. Kurtz does discuss one category of studies that present data on " Advocacy and Empowerment" processes within self-help groups. These are processes that involve aspects of civil rights and protest social movements.

Most references in the literature on the social movement status of self-help are casual comments or assumptions that lick either the careful delineation of the concept or the inclusion of empirical data that would be necessary to evaluate the assumption. Some recent treatments of the self-help movement, particularly in America, more clearly suggest its social movement status (Borkman, 1990; Chamberlin, 1978, 1990; Dain, 1989; Everett, 1994; Farber, 1993; Katz, 1993; McKinnon, 1986; Medvene, 1985; Pilgrim and Rogers, 1993; Scotch, 1988, 1989). However, serious evaluations of the social movement status of self-help groups generally characterize them as only marginally fitting the definition.

A 1976 study by Back and Taylor uses Turner's (1969) classic distinction between expressive and instrumental social movements as a basis for concluding that self-help is, at best, an "expressive movement" that serves individual emotional needs of belonging, rather than promoting any type of political stance or activity regarding social change that would qualify it as a true progressive and instrumental social movement.

"The vague, general sentiment of self-help groups gives them the character of a social movement -as important as other expressive movements in history." (Back and Taylor, 1976, p. 307)

Riessman and Gartner (1987) echo this characterization of self-help as a conservative, individually-oriented, expressive social movement dominated primarily by a "self-help ethos." Despite the acknowledgment of self-help themes such as self-determination (empowerment), anti-bureaucratic "pro-sumerism," and the noncommodifiable character of help based on experiential wisdom, these psychologists do not believe that self-help groups constitute a true progressive social movement.

Similarly, even some sociologists argue that "self-helpers seem uninterested in identifying with any larger self-help group movements" (Borkman, 1990, p. 327). Borkman concludes that self-help groups are, at best (1) "instrumental self-help social movements," that focus on a single condition or disorder and promote changes in individual sufferers, and (2) "expressive social movements" that promote individual emotional support regarding community values and a sense of belonging (p. 327).

Katz and Bender (1990) address the ambiguity in the literature regarding the social movement status of self-help. They present a detailed argument against the social movement characterization of self-help groups. Katz and Bender come to this conclusion by applying criteria from the traditional sociological literature on social movements. Despite evidence of "the continuous and probably permanent proliferation of self-help groups in modern society," and although "there are so many apparent similarities between the activities of self-help groups and those of recognized social movements," Katz and Bender conclude that "most self-help groups lack the unifying goals, culture and symbolism" characteristic of true social movements (1990, p. 97). Specifically, they believe that self-help groups are not uniform enough with respect to their ideology, goals, internal structure, functions, and procedures to be a social movement.

Katz and Bender admit the applicability to the self-help movement of Hans Toch's (1965) classic description of the psychological motivation for joining a social movement:

"When people feel themselves abandoned or frustrated by conventional society, they can sometimes bypass established institutions and create informal organizations "on the side." Such grass-root movements serve to provide otherwise unavailable services, to protest indignities, to escape suffering, to relieve tension, to explain confusing events, or in some way to create a more tolerable life than is afforded by existing formal organizations." (Katz and Bender, 1990, p. 95)

However, Katz and Bender argue that the most important criterion for determining whether self-help groups constitute a social movement is "the extent and significance of the social changes brought about or influenced by them" (p. 97}. While they credit some important social changes to the self-help movement, like the self-help focus of the Social Programs Branch of the Canadian Department of Health and Welfare and the 1978 President's Commission on Mental Health recommendations promoting self-help organizations and philosophy, Katz and Bender imply that these examples of social change are not enough to justify the conclusion of social movement status.

By contrast, Everett (1994) has pointed to the Ontario government's recent mental health reform policy report entitled Putting People First (1993) as a "concrete example of how (psychiatric] consumers and survivors have affected reform" (p. 66) .She notes that "large numbers of consumers and self -declared survivors participated in a variety of planning groups that culminated in the production of the report" (p. 66). The plan includes the creation of four community-based programs (a case management program, a 24-hour crisis intervention program, a housing program, and a social support program) that are to be "planned and run by consumer/survivors and families as alternatives to the formal mental health system" (Putting People First, 1993, p. 17, emphasis added). Everett also cites the Canadian Consumer/Survivor Development Initiative (CSDI) which funded thirty-six self-help projects in Ontario as a prototype of significant self-help movement activities that resulted in institutional social changes in national mental health policy.

These ambiguous and outright conflicting claims in the research literature regarding the social movement status of mad liberation may be explained in terms of the sociology of knowledge perspective which locates differing versions of truth within their respective social and subcultural contexts. Since most researchers within the self-help literature are psychologists, social workers, or psychiatrists, it may not be so surprising that they have largely missed the progressive social movement character of many former mental patient self-help groups.

The Sociology of Knowledge and the Mad Liberation Movement

The Sociology of Knowledge and the Sociology of Science

Berger and Luckmann (1967) define the "sociology of knowledge" as the concern with "the analysis of the social construction of reality. . ." and point out that

". . . specific agglomerations of "reality" and "knowledge" pertain to specific social contexts, and that these relationships will have to be included in an adequate sociological analysis of these contexts." (p. 3)

The "sociology of science" is the specialized study, within the sociology of knowledge, of the social construction of scientific knowledge. Early formulations in the philosophy of science and the sociology of knowledge and science {1930s - 1960s) promoted the assumption that "scientific knowledge is somehow special and different from other kinds of knowledge" {Clarke and Gerson, 1990, p. 180). More recent theory in the sociology of knowledge focuses on science more as work that emerges from specific interactional and social organizational settings than as "knowledge" to be taken for granted as objective truth. This modern sociological perspective on the sociology of knowledge and science is based on four assumptions.

"The first assumption . . . .is that all scientific facts, findings, and theories are socially constructed. . . . Second. . . knowledge represents and embodies work, a particular way of organizing the world through a series of commitments and alliances. . . . The third basic assumption. . . is that science is best approached as a matter of work, organizations, and institutions. . . . Fourth. . . scientific work, institutions, and knowledge are not essentially different from other kinds, nor in any way sociologically special." (Clarke and Gerson, 1990, pp. 181-182)

These assumptions may help us to begin to understand how different kinds of scientific researchers, trained in different academic disciplines, ask different kinds of research questions, employ different kinds of research methods, and construct different versions of the realities they purport to explain. Scientific findings, like all social "truths," are unintentionally socially constructed based on the working commitments and alliances of the researchers. Thus, as sociologists of science, we would expect to find that individualistically-oriented researchers, like psychologists, psychiatrists, and social workers, are more likely to construct individualistic versions of reality, while more socially-oriented researchers, like sociologists, anthropologists, and political scientists, are more likely to develop collectivistic versions of the very same reality or to discover different areas of the same reality. We would also expect to find that individualistic analyses of "psychiatric" realities would adopt and promote a conservative individual-change or therapeutic point of view, while collectivistic versions of psychiatric worlds would more likely perceive and promote a progressive social-change interpretation. The sociology of knowledge and science perspective suggests that, as a social institution, "science" and its agents, scientists, like others, are unwittingly and inevitably caught in the value biases of their culture, or subculture, their personal histories (including their academic training), their working environment, and the era in which they find themselves (Gould, 1978).

Academic Training and Professional Context

Particular kinds of scientists, because of specific biases built into their academic training and their work-a-day professional worlds, operate with values that predispose them to see the world, especially their research realities, in ways that are different from other scientists and lay people. In the self-help literature, most of the research over the last twenty years has been done, not surprisingly, by those "psychological" scientists whose worldviews and daily work environments are most directly implicated in the helping professions. Both the academic training and the clinical and community practice of these mental health system professionals promote attitudes of biological and psychological reductionism that result in the study of particular kinds of self-help groups in terms of specific professional interests. Psychiatrists and psychologists, in particular, are professionals whose academic training and professional practice predispose them to think in intra-individual, i.e., biological and psychological terms. Social workers are traditionally more likely to find themselves dealing with community organizations and agencies so that, despite their psychologistic training, they are more likely to think in terms of problems at the social or group level of analysis. Sociologists, and other collectivist scholars, are much more likely to ask questions and use methods that reflect and promote a socio-political interest in the study of the self-help movement.

In fact, a review of the self-help literature shows that the three types of psychological researchers usually study those self-help groups that I call "pro-professional groups" or "therapy groups" (Emerick, 1989, 1990, 1991, 1992), the most conservative types of self-help groups. Everett calls these "consumer groups" and distinguishes them from the more radical "psychiatric survivor" groups (1994, p. 63). These conservative consumer groups include those associated with Recovery Inc., Grow Inc., Emotions Anonymous, and the Manic Depression and Depression Association (MD&DA). These are groups that adopt the Alcoholics Anonymous twelve-step-type programs and are largely apolitical, quasi-religious, individual-change oriented, "alternative therapy" groups. These conservative self-help programs, indeed, promote the ideology of self-help as a social support context within which individuals might learn how to make changes in their lives, as opposed to social changes. Studies of such groups reflect the most conservative, individualistic interpretation of the self-help goal of "empowerment." My self-help research suggests that these groups are in fact relatively isolated from the political agendas and activities of the more numerous social-change oriented or "survivor" self-help groups that make up the civil rights movement among ex-mental patient groups (Emerick, 1989, 1995).

Most of the traditional self-help studies deal with (1) the "efficacy" of self-help in terms of individual change, as defined and measured by standard clinical scales of mental health functioning, and (2) questions relating to the development of "partnerships" between self-help groups and mental health professionals. Questions about self-help partnerships seem to reflect the fears of professionals regarding the potential turf encroachment of this increasingly popular form of "psychiatric first aid," rather than suggesting an interest in the political advocacy and legislative change activities of the more radical social-change version of self-help empowerment. After all, the kinds of social changes advocated by the mad liberation movement reflect directly on the mental health system and the professionals who represent it. Since the personal and professional veracity of these researchers is being questioned by the radical anti-psychiatry and anti-mental health system activities of these mad liberation groups (Dain, 1989), it is not surprising that mental health professionals are less than enthusiastic about acknowledging or studying these groups.

Despite obvious differences in their academic education and training, psychologists, social workers, and psychiatrists share many theoretical assumptions about the nature of human nature, human problems, and the kinds of responses that are appropriate. Obviously, both clinical and academic psychologists, by virtue of their academic training, are interested in individual behaviour, thought, and feelings, often considered in terms of the individual's social and cultural setting. By contrast, psychiatrists, because they are medically trained and clinically situated, usually think and operate in intra-individual, biological, and pathological terms that are asocial and acultural. Thus, psychiatrists are generally more biochemical in their orientation toward "patients" than psychologists and social workers are toward their "clients." But despite these differences, all three professional groups are taught, trained, and immersed daily in the theories, philosophies, and practical applications that promote what Scheff (1990) calls "the myth of individualism" and "the myth of simplicity" regarding the nature of human behaviour and human social systems. These biases limit both the kinds of groups that traditional self-help researchers have studied and, what is more important, the kinds of research questions they have sought to understand in the study of empowerment in self-help groups.

The Myth of Individualism

These three individualistic disciplines focus on the human being as a separate unit of analysis known as "the individual." Psychology, psychiatry, and social work all derive historically from the school of philosophical nominalism. These seventeenth-century nominalist philosophers argued that the individual existed before society and, for one reason or another, created society as a contractual relationship between individuals (Becker and Barnes, 1961).

The resultant "ideology of individualism" that dominates psychology, psychiatry, and social work theory and practice explains, in part, the tendency of traditional self-help researchers to portray a panoply of disparate individuals, seeking self-centred personal assistance, in unrelated and isolated self-help groups. Self-help groups that have been developed in mental hospitals, or by mental health professionals, are the kinds of politically conservative, pro-professional, and politically disconnected groups that these professionals are most likely to be aware of and to study. Research on these kinds of groups confirms the biases of individualism. It is therefore not surprising that these researchers tend to ignore, or are unaware of, the ex-mental patient civil rights movement as a social movement.

The Myth of System Simplicity

A corollary of the ideology of individualism is the myth that human beings are determined by natural forces that are understandable through the methods of positivistic science. Most theories of human nature assume that human systems, whether biological, psychological, or social, are relatively simple. Human beings and human behaviour are portrayed within the psychological disciplines as simply extensions of their physical and biological environments. Like the natural world around them, they are systematically and ultimately understandable only by experts with highly specialized knowledge and training in the use of the predictive methods of positivistic science. Harvard palaeontologist Stephen Jay Gould (1984) has labelled such beliefs "the myth of determinism," one of several errors typical of Western scientific thinking.

The biases of simplicity, determinism, and scientific positivism have played a role in skewing the self-help literature away from the conceptualisation of self-help groups as a social movement. It has been noted that this literature is replete with case studies of isolated, individual, conservative twelve-step-type "assimilative" or "alternative therapy" groups. These studies emphasize the measurement of individual group members' needs and goals as they relate to the group. There is no mention in this literature of the many examples of political activism and significant social change brought about by members of the mad liberation movement. Following a discussion of the evolution of social movement theory in sociology, I discuss below some practical and progressive social change accomplishments of the mad liberation social movement.

The Theory of Social Movements and the Mad Liberation Movement

Traditional Theories of Social Movements

The classical approach to the study of social movements derives from traditional collective behaviour theory (Freeman, 1983; Gerlach, 1983; Lawson, 1983). This theory is based on studies of social movements during the early decades of the twentieth century -movements characterized by the theory as necessarily evolving from an initial stage of social unrest, through increasingly formalized stages of organization, and ultimately to a fully institutionalised social organization (see Dawson and Gettys, 1935; Blumer, 1939/1974; Turner and Killian, 1972). One classic definition of a social movement was presented by Turner and Killian (1972) as "a collectivity acting with some continuity to promote or resist a change in the society or group of which it is a part" (p. 223). During the 1970s the collective behaviour approach to social movements was augmented by the resource mobilization approach (Jenkins, 1983; Lawson, 1983). This "social exchange" theory of social movements

". . . regards movements as rationally created to pursue certain group and/or individual goals, to which ends resources, especially both labour and capital. are mobilized." (Lawson. 1983. p. 121)

Contemporary Theories of Social Movements

In contrast with traditional social movement theory, Gerlach and Hine (1970), Freeman (1983), and Caplow (1991) study social movements of the 1960s through the 1980s and portray modern social movement structure as "segmentary, decentralized, and reticulate" (Gerlach and Hine, 1970, pp. 33-78). That is, they argue that many contemporary social movements are composed of relatively autonomous local groups (segmentary), that leadership is often very localized and without central control (decentralized), and that local groups are linked together largely through interpersonal networks and other inter-group linkages rather than through some central organization (reticulate).

Theodore Caplow (1991) points out that modern civil rights movements attempt "to raise the status of a disadvantaged social group," and that modern protest movements seek "to change official policy towards an activity which the protestors want to see promoted or suppressed" (p. 201). He also contends that modern social movements "often come in matching pairs." The vigorous and well-funded National Alliance for the Mentally III (NAMI), which supports and promotes NIMH programs that emphasize biochemical research on "schizophrenia" and forced treatment of "the mentally ill," represents the matching pair countermovement to which the mad liberation movement is, in part, a response. Most of the advocacy and empowerment activities of the mad liberation movement are designed to raise the status of this disadvantaged group (they call it "stigma-busting") and to change laws and mental health system policy regarding commitment and treatment practices (the "right to refuse" and "right to treatment" themes). These more contemporary theories of social movements help us to perceive such progressive and liberating accomplishments that provide support for the argument that the mad liberation movement is indeed a modern civil rights and protest social movement. Clearly it is important whether students of self-help groups adopt the more traditional collective behaviour or resource mobilization theories of social movements or the more contemporary decentralization theories of Gerlach and Hine or Caplow in understanding whether they evaluate self-help groups as true social movements.

The Case for the Social Movement Status of Mad Liberation

In terms of both quantitative empirical data and more intuitive understandings based on talking with hundreds of self-helpers during my study of psychiatric self-help groups, I argue that a significant mad liberation self-help social movement has been emerging over the last twenty years, one that clearly fits the criteria in the contemporary social movement literature. In contrast with the typical individualistic focus of earlier research, I have been more interested in understanding the pervasiveness and distribution of self-help groups throughout the United States (Emerick, 1989); the types of political factions that have developed within the self-help movement as this relates to interactional support and group longevity (Emerick, 1991); the degree of networking and organizational interaction between different types of groups (Emerick, 1992); and the range of political ideologies and activities of these groups, particularly vis-à-vis mental health professionals and agencies (Emerick, 1990, 1995). These data support the belief of many self-helpers within these groups, that self-help can be, and is, a meaningful progressive civil rights and protest social movement. Below I discuss the case for a self-help social movement in terms of my data and research experiences using the same criteria from the sociological social movement literature that Katz and Bender use to argue the case against.

Structural Strain, Awareness, Control, and the Emergence of a Social Movement

The academic anti-psychiatry movement of the 1960s and 1970s and the political economics of the resultant community psychiatry movement reflect some of the structural factors that fostered the emergence, in the early 1970s, of former mental patient support groups across the country (Chamberlin, 1978, 1990; Dain, 1989; Everett, 1994). Today politically active self-help movement groups are not only engaged in legal and political activism that promotes serious social change, but many are also dedicated to the organizational development of a national self-help movement. The names of some of their newsletters suggest their progressive social movement orientation:

Madness Network News: A Journal of the Psychiatric Inmates' Liberation Movement Mad Lib: The Voice of the Ultimate Civil Rights Movement

Inmates' Voice: News Journal of the Alliance for the Liberation of Mental Patients

The Commitment Papers

The Alternative Press

Phoenix Rising: The Voice of the Psychiatrized

One recent study presents a political content analysis of fifty ex-patient self-help group newsletters (Emerick, 1995). Based on the analysis of news items and editorial policies in these self-help publications, this study concludes that the mental patient movement is a progressive social movement. Smelser's (1962) theory of the rise of social movements would predict that the development of a national network of awareness, promoted by annual conferences and the many newsletters, magazines, and books published by mental patient self-helpers, fosters a mobilization of interest and participation in the mad liberation movement.

The issues of professional co-optation and control of self-help groups and the encroachment of self-help into "professional territory," by what are seen as untrained lay people, are hotly debated topics that have been the subject of both self-help conferences (Zola, 1987a, 1987b) and self-help articles (Chamberlin, 1990; Emerick, 1990, 1995). Back and Taylor (1976) point out that "[o]ne of the most striking characteristics of self-help adherents is distrust of professionals" (p. 301). By contrast, Medvene (1984) suggests that "[o]ne wide-spread misunderstanding is the attitude on the part of the professionals that self-help groups are anti-professional" (p. 16). My research provides strong evidence that Back and Taylor are correct. Self-help groups and their ideologies are largely antithetical to the professional health care system. Riessman (1990a) concurs when he says that "the two approaches. . . are essentially in a dialectic relationship" (p. 228). Thus, many mental health system professionals either reject the self-help philosophy out of hand or look askance at the whole business as an example of "the blind leading the blind" (Riessman, 1990b, p. 42).

"There is a natural, typically unstated professional resistance to the new [self-help] paradigm, despite the fact that it is advocated by many professionals. . . . Professionals are reluctant to share their help-giving role and they have a business-oriented reason for wishing to maintain a large number of dependent help receivers." (Riessman, 1990a, pp. 226-227)

Nonetheless, some students of the self-help phenomenon have suggested the need for professionals to become more knowledgeable about these groups and to become more involved with them, despite the fact that self-help/professional "partnerships" are inherently difficult to accomplish (Emerick, 1990; Kurtz, Mann, and Chambon, 1988).

Social, Political, and Legal Change

While they acknowledge some social change brought about by self-help, most self-help researchers seriously underestimate the quantity and quality of the social changes that have resulted from the organizational movement activities of self-help groups. This is true even though a number of leaders in this movement have published articles and books that, taken together, constitute a detailed historical accounting of events in the emerging mad liberation movement (Budd, Harp, and Zinman, 1987; Chamberlin, 1978, 1990; Everett, 1994; Lapon, 1986; McKinnon, 1986). This historical analysis of the developing movement written by those who participated in it, has, to my knowledge, never been cited in "professional" self-help studies other than my own. Apparently, most self-help researchers are simply unaware of this progressive civil rights movement interpretation of the history of the mental patient self-help movement. One possible exception to this is Farber's Madness, Heresy, and the Rumour of Angels (1993), which cites and quotes several leaders of the mad liberation movement, although strictly speaking this is not a study of the self-help movement. Another exception is Dain's (1989) article on "Critics and Dissenters" which directly links the ex-mental patient movement with the broader "Anti-Psychiatry" movement in the United States.

Generally, this history links the current self-help movement to the liberal "anti-psychiatry movement" of the late 19605 and early 1970s, most of which was promoted by academics writing in the professional literature (Foucault, 1965; Goffman, 1961; Laing, 1967; Scheff, 1966; Szasz, 1961), but which clearly had an impact as it coalesced with more conservative and libertarian political and economic forces that, together, ushered in what is known as the "community psychiatry movement" (Brown, 1985; Ingleby, 1980; Sedgwick, 1982). Many self-helpers in the mad liberation movement are well versed in the academic anti-psychiatry literature and understand that the changes in the resulting federal, state, and local funding for mental health services formed a significant source for the germination of their social movement (Chamberlin, 1990; Everett, 1994).

Since the early 1970s former mental patients have been organizing and meeting in groups to discuss their dissatisfaction with the American Psychiatric Association in general and their personal experiences as mental patients in particular (Chamberlin, 1978, 1990; Everett, 1994; McKinnon, 1986). The movement began with a number of very radical annual conferences under the banner of the International Organization For Human Rights and Against Psychiatric Oppression (FHRAPO). In recent years these meetings have become formalized as the annual Alternatives conference, now funded in part by the Community Support Program of the National Institute of Mental Health (NIMH). At these conferences, convened every year since 1985, various national ex-mental patient "self-help" organizations present seminars, workshops, talent shows, and barbecue dinners in a progressive, activist context where the ever-present, and not always latent sub-theme is that of 'mad liberation" (l) -the belief that the ultimate in human degradation and civil rights deprivation is the experience of being dehumanised by being officially certified and treated as "mentally ill." Goffman (1961) called this experience "social mortification" (pp. 125-169), and the extensive denial of civil rights that accompanies the mental patient role (see, for example, Farber, 1993; Scheff, 1966) is, of course, the reason why the mental patient self-help movement characterizes itself as the ultimate civil rights movement.

Hundreds of ex-mental patient self-help groups from throughout the nation send representatives to the Alternatives conferences, which, in recent years, have attracted 500 to 800 and more attendees. The tenth and eleventh annual Alternatives conferences were held in Anaheim, California and St. Paul, Minnesota in 1994 and 1995, respectively. The local groups who attend these conferences represent the whole range of left-to-right political factions regarding the social role of psychiatry in America and the meaning of "mental illness" and its "treatment." However, the theme of the conference, like the theme of the mad liberation movement itself, is decidedly "anti-psychiatry." Alternatives '91, entitled "Unifying Through Diversity, Empowered With Dignity," convened in Berkeley, California. The conference drew together several hundred ex-mental patients and "friends of the movement" who met for four days of workshops, caucuses, and plenary sessions dealing with such diverse, but clearly civil rights-related topics as Advocacy Through Education, How to Get Off Psychotropic Drugs, Spreading Empowerment, Patients' Rights, Overcoming Stereotypes, Current Self-Help Research, and The History of the Movement. The conference catalogue includes an article on "The Berkeley Alternative" which points out that

"The movement of consumers and psychiatric survivors, dating at least from. . .the Insanity Liberation Front in 1972 has flourished in America during the recent decade, and continues to find vibrant expression in the tradition of Alternatives Conferences." (Moore, 1991, p. 9)

One consequence of these yearly gatherings, which most professional self-help researchers seem to be unaware of, was the emergence of two competing national organizations, the National Mental Health Consumers Association (NMHCA) and the National Alliance of Psychiatric Survivors (NAPS). Each of these organizations claims to represent the civil rights and interests of current and former mental patients better than the formal mental health system. These two organizations went through many battles to a standoff in which, for several years, each was equally represented at the annual Alternatives conferences. Based on social movement theory, which predicts that radical and progressive movements become less radical over time as they move toward institutionalisation within society, the fact that the more radical national self-help organization (NAPS) has atrophied in recent years, leaving the more moderate NMHCA as the leading national organization for the movement, is a sign of the maturation of this social movement. The annual Alternatives conferences have become such well-attended and meaningful organizational activities for the mental patient movement that the National Institute of Mental Health has begun, in recent years, to participate in an adjunct fashion by providing travel funds and other organizational assistance through the Community Support Program (CSP), which now has a liaison officer who attends and participates in the annual event.

The CSP has also been involved in providing demonstration grants to fund various self-help programs organized and operated by self-helpers, rather than professionals. NIMH also now funds at least two national self-help research and information dissemination centres that include many consumers and survivors on their boards and in their daily operations. The Centre for Self-Help Research and Knowledge Dissemination is located in Ann Arbor, Michigan and the Centre for Self-Help Research is in Berkeley, California. Similarly, the State of California, through its Department of Mental Health, has funded research and mental health services that are run exclusively by self-help consumer/survivors (Campbell, 1989; Campbell and Schraiber, 1989).

Another annual event of the mad liberation movement is the protest demonstration at the yearly meeting of the American Psychiatric Association. In 1987 the APA conference theme was "Medicine in Psychiatry, Psychiatry in Medicine," reflecting the strong biological emphasis of "the new psychiatry" in America. The mad liberationists carried placards displaying the slogan "Psychiatry in Social Control, Social Control in Psychiatry" during their counterdemonstration.

The mental patient movement also takes some credit for promoting the Weicker Bill that resulted in the passage of the Federal Protection and Advocacy for Mentally Ill Individuals Act of 1986 (The P&A Act). Funding from the PM Act is allocated in many states directly to various kinds of legal advocacy programs run by mental patient consumer/survivors and their self-help groups. South Carolina uses P&A money to fund state mental hospital inspection teams, comprised solely of ex-mental patient advocates, who conduct surprise inspections of state facilities and file reports with the state Department of Mental Health.

Hundreds of mental health consumers and survivors lobby legislative bodies at the state and federal level, sit on mental health boards as consumer representatives, advise current patients of their civil rights regarding "right to treatment" and "right to refuse treatment" laws, and advocate for patients' rights in psychiatric intake and conservatorship hearings. Other ex-patients are involved in lobbying legislators for the passage of more liberal commitment and treatment laws nationwide. Many high profile legal cases involving psychiatric patients and the right to refuse treatment or the right to treatment (e.g., Riese v. St. Mary's Hospital, Rogers v. Department of Mental Health, and Rennie v. Klein), and cases involving questions about "stigma" in the workplace and elsewhere, are in part the result of the efforts of ex-patient consumer/advocates from the mad liberation movement. A number of self-help consumers are lawyers, or former lawyers, who have played a direct or indirect role in some of these landmark legal cases.

Another important legal advocacy accomplishment of the mad liberation movement is the National Association for Rights Protection and Advocacy (NARPA). Started in the early 1980s by mental health consumer/survivors, NARPA is an organization dedicated to the promotion of policies and laws that help empower people labelled "mentally disabled" to make their own choices "so that they may independently exercise their legal rights" (from the "mission statement" in The Rights Tenet). NARPA is a non-profit, membership-supported organization. Its two major activities are the publication of a quarterly newsletter, The Rights Tenet, which deals primarily with legal issues relating to psychiatry and mental health policy, and the annual NARPA conference. The Rights Tenet always includes a column by one of the most outspoken "anti-psychiatric" psychiatrists, Peter Breggin, as well as other anti-psychiatric articles and columns. The NARPA conference, in its fifteenth year in 1996, is considered one of the important events within the mad liberation movement. Approximately 250 people attend the NARPA conferences, one-third of whom are lawyers, one-third are consumer/survivors, and one-third are other professionals, with considerable overlap among the three categories. The conference addresses issues of legal advocacy for mental health clients, protection and advocacy issues relating to the national Protection and Advocacy Law, and establishing and maintaining alliances with people who have similar civil rights interests (e.g., the physically disabled, women's groups, ethnic and racial minorities, and gays and lesbians). The radical anti-psychiatry orientation of this organization, its legal empowerment and advocacy efforts, and its outreach and networking interests clearly suggest the operation of an element of a progressive social movement.

My reading of this history concurs with the self-helpers' own interpretation, that many substantial social, political, and legal changes over the past ten to fifteen years are the direct result of the advocacy and empowerment activities that have come out of the mad liberation movement. These changes clearly point to the mental patient self-help movement as a progressive protest and civil rights social movement.

Networking, Recruitment, and Ideology

Gerlach and Hine (1970) define social movements in terms of the networking organizational processes within the movement, recruitment practices, the personal commitment of the members, a unifying ideology, and opposition to and from the established order. There are many examples of these types of activities within the mad liberation movement.

Antze (1976) has argued, for example, that most researchers have simply not paid sufficient attention to the ideologies of self-help groups. This is an expected consequence of the psychologistic bias in the self-help literature. In fact, recent sociological research shows that local ex-patient self-help groups are distributed along a broad continuum of political ideologies, with approximately 21% in conservative or pro-professional organizations and about 79% in both moderate and radical anti-professional ("anti-psychiatry") groups (Emerick, 1989, 1990, 1991, 1992). The conservative local groups affiliate with national organizations such as the National Alliance for the Mentally III [NAMI] (a pro-psychiatry, pro-medical group of "parents of patients" or "secondary consumer" groups) and Recovery, Inc. (a conservative, pro-psychiatry "therapy" group). The more radical local groups associate themselves with national organizations such as Truth in Psychiatry (a network of groups dedicated to abolishing shock treatment) and the Support Coalition International (an organization that promotes the abolition of the medical model in psychiatry and supports the universal right of patients to refuse psychiatric treatment). As divergent as these local groups are, they manage to engage in a great deal of "networking" with each other throughout the year at local and state-wide conferences and on various mental health boards, and annually at the national Alternatives conferences. The amount of interaction between groups is inversely related to their attitudes toward professionals. Conservative, pro-psychiatry groups network with mental health system and institutional organizations, while the more radical, anti-psychiatry groups interact more frequently with other, within-the-movement, self-help groups (Emerick, 1990, 1991). However, in general the extent and type of networking fits Gerlach and Hine's criteria of a "decentralized, segmentary, and reticulate" social movement (1970, pp. 33-78).

An avowed purpose of the annual Alternatives conferences is to engage in face-to-face recruitment of local self-helpers into one of the national organizations (NMHCA, NAPS, Reclamation, Inc., NAMI, Recovery, Inc.). Those national leaders who organize and run the conferences each year systematically proclaim their own self-help "conversion experiences" to the gathered congregation in various keynote addresses, plenary sessions, workshops, display booths, and open microphone sessions. Often I have heard people at these gatherings proclaim some variation of the theme that "The movement is my life!" -that before self-help they were depressed and disoriented regarding their lives and the problems that led to their hospitalisation, that they were mistreated in the mental health system, and that now they can make sense of what happened to them in terms of social consciousness-raising, empowerment, and advocacy work. This type of face-to-face testimonial recruitment of new members illustrates one element of Gerlach and Hine's definition of a progressive social movement (1970, pp. 79-97).

The concepts of "self-help," "empowerment," and "consciousness-raising" constitute a unifying ideological banner that brings together hundreds of disparate types of self-help groups through various conferences and nationally distributed newsletters. The 1989 Chicago Symposium on the Impact of Life-Threatening Conditions: Self-Help Groups and Health Care Providers in Partnership (Emerick, 1992) is an example of just this kind of ideological display of commitment. Although very few health care professionals attended this conference, indicating perhaps some degree of threat felt by "establishment" types, the 300 attendees represented many different types of self-help groups. This included, for example, such diverse groups as those that deal with facial disfigurement, drug abuse, dry-eye syndrome, bereavement, various mental and emotional problems, and cancer support groups. The common ideological theme was self-help, empowerment, and the need to promote more communication between the different types of groups, and between self-help groups and health care professionals. A recent book entitled Self-Help: Concepts and Applications includes many of the theoretical and research papers presented at this symposium (Katz et al., 1992). The symposium also generated interest in the development of a new, specialized self-help journal. Plans for the publication of this journal have recently been finalized, so that self-help researchers and self-help consumers should have a publication outlet for the dissemination of self-help information by late 1996. The journal will be housed at UCLA under the general editorship of Alfred H. Katz. The title for the new journal is The International Journal of Self-Help and Self-Care.

A common theme of the mad liberation movement is opposition to the society-at-large, particularly regarding the widespread prevalence of stigma, prejudice, and discrimination against people labelled mentally ill. "Stigma busting" is a major organizing theme of the movement. As Dain (1989) points out the movement is also generally opposed to the American Mental Health System (the National Institute of Mental Health, the American Psychiatric Association, and the psychiatric facilities used to involuntarily commit and "treat" people against their will -those segments of the "therapeutic state" to which the movement is a reaction). The notion that "psychiatry is social control" is a popular theme of the movement. Again, my research shows that most mental patient self-help groups (about 79%) are strongly anti-professional or anti-psychiatry, while relatively few (about 21%) are pro-psychiatry (Emerick, 1989, 1992, 1995). Gerlach and Hine emphasize the importance of oppositional forces in social movement activities (1970, pp. 183-197). Both my qualitative research experiences and my quantitative empirical data suggest that the Gerlach-Hine conceptualisation of a social movement aptly characterizes the mad liberation movement.

The Thirteenth Step - Social Consciousness Raising

Katz and Bender demonstrate the bias of the psychologistic perspective in their claim that most self-helpers feel that they have been dealt "an individual, rather than a collective 'injustice' or deprivation" (1990, p. 103). This is clearly not true with my national survey of ex-mental patient self-help groups, wherein one major reason for joining "the movement" is precisely a rise in the level of social consciousness regarding the social, cultural, and political-economic understanding of the problem of "mental illness." It is in fact a major purpose of the annual Alternatives conferences and the many movement newsletters and journals (Emerick, 1995) to promote a collective level of consciousness -sometimes called "taking the thirteenth step," an important step beyond what most twelve-step programs address. Regarding other types of self-help groups, the 1989 Chicago symposium made it clear that people with all sorts of "problems," from dry-eye syndrome to spouse abuse, realize that a major function of the general self-help movement is the need to inform and educate both the public and the professional care giving subculture about the socio-political aspects of their particular ordeal (Emerick, 1992). This general theme of raising the level of social consciousness is seen as part of the solution to the problem of "stigma" in society.

The same could be said of Katz and Bender's observation that people join self-help groups "to obtain personal assistance, rather than to affiliate with and further an impersonal social movement" (1990, p. 102). My research shows that those who join these self-help groups do so because of their realization of the importance of a more collective understanding of "mental" problems and the benefits of a social, rather than an individual, response to them. These people understand that the major theme of the contemporary self-help movement is that "personal assistance" is, by definition, a collective matter, both in terms of the definition and the resolution of problems. Everett (1994) echoes this theme when she says that "the personal is the political" (p. 61). Spano (1982) agrees and contends that the "consumer" and "survivor" camps of the mad liberation movement are really just two sides of the same coin. And Melucci concurs by pointing out that the new social movements "don't separate individual change from collective action" (1985, p. 812). Thirty years ago Hans Toch characterized self-help movements as inevitably involving simultaneous individual and social change.

"Another consequence of the nature of self-help movements is the fact that the solution of personal problems is placed in a wider context. Each individual's efforts to solve his own problems become part of his efforts to solve a social problem. . . . When a person resorts to a social movement for the solution of a private problem, his actions have inescapable social consequences. To the extent to which he participates in the collective effort, he changes society as he changes himself." (1965. pp. 84-85, emphasis in the original)

My experience has been that the ex-mental patient movement is dominated by this theme of "working together" to forge a new kind of cultural symbolism and social response to overcome the age-old deficiencies of individualistic, biologistic, and medical approaches to "mental illness" as an individual disorder or disease. Most of the subjects in my studies reject both the "medical model of mental illness" and "the myth of individualism" (Emerick, 1989, 1990, 1991, 1992, 1995). The fact that more than 70% of the groups in my national survey evidence attitudes and behaviour that are "anti-professional" or "anti-psychiatry" calls into question the claim that "the majority of present self-help groups do not challenge the existing social order, or seek to replace it" (Katz and Bender, 1990, p. 102). A significant subset of self-help groups involved in the mad liberation movement is very politically active precisely because it sees the need to challenge existing complacency and misunderstanding regarding "mental illness" and its treatment, both in the society at large and within the mental health care-giving system. These self-helpers, for the most part, are not interested in "assimilative" approaches in which they simply change themselves so that they better fit in with the status quo. Instead, they actively engage in "assertive" programs designed to change the social order (Emerick, 1989, 1991, 1995). From this perspective, the mad liberation movement fits very nicely into Turner's (1969) theme of contemporary social movements that emphasizes collective activities directed toward correcting social injustices that are seen as no longer tolerable,

Summary and Conclusion

The banner of self-help, and the underlying symbolism of empowerment, self-reliance, consciousness-raising, stigma-busting, and various forms of legislative advocacy and social change, establish strong subcultural themes that do indeed unite all forms of self-help. This is particularly apparent in the mad liberation movement. There are also several levels of organizational structure -from the highly structured national organizations like NMHCA, to a large number of informal, decentralized local self-help support groups within the movement. My self-help movement research was based on a sample of 346 local self-help groups (Emerick 1989, 1990, 1991, 1992). From this I estimate that there are more than one thousand such groups nationwide. My national survey of the mad liberation movement found that only a minority of mental patient self-help groups fit the definition of individual-change oriented, "consumer," or "therapy groups" (37.5%), while most groups (62.5%) qualify as social-change oriented, "survivor," or "movement groups" (Emerick, 1990). These groups engage in and promote various types of social and political self-help activities. These include legal advocacy, educational and technical assistance, and information and referral work. Most "mental patient" self-help groups perform progressive social movement activities every day (Emerick, 1989). Thus, this movement may be aptly characterized as in the midst of a long, slow process of emerging organizational structure.

The sociology of knowledge perspective helps us to account for the fact that most of the earlier self-help literature depicted self-help groups as conservative, individual-change oriented or "consumer" groups. The psychological biases of traditional self-help researchers explain their failure to acknowledge or perceive the progressive social movement nature of the numerically predominant "psychiatric survivor" types of self-help groups.

I propose that we need more self-help group and self-help movement research that reflects the philosophy of social realism, emphasizing the importance of social and cultural context, and adopting the biases of an overtly political and social systemic orientation. If more sociologists, political scientists, and anthropologists become interested and involved in the study of the self-help phenomenon, there will undoubtedly be more research forthcoming that supports the interpretation that self-help is a social movement. Despite the long history of the domination of this research area by psychologically-oriented researchers, the increasing proliferation of self-help groups, their greater visibility as a result of making significant changes in mental health policy and law, and their increasing acceptance as an important social movement by those who make research and program funding decisions, may bring a broader array of academic researchers into this field in the near future. I suspect that a review of the self-help research literature at the end of the 1990s will include much more sociological discussion about the status and the successes of the self-help social movement than is currently found there. The facts demand this kind of understanding.

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1, One ex-patient self-help group in Washington D.C. actually calls its newsletter Mad Lib and uses the motto "The Voice of the Ultimate Civil Rights Movement."